Asthma control and care among six public health clinic attenders in Malaysia: A cross‐sectional study

Abstract Background and Aims Asthma is common in Malaysia but neglected. Achieving optimal asthma control and care is a challenge in the primary care setting. In this study, we aimed to identify the risk factors for poor asthma control and pattern of care among adults and children (5–17 years old) with asthma attending six public health clinics in Klang District, Malaysia. Methods We conducted a cross‐sectional study collecting patients’ sociodemographic characteristics, asthma control, trigger factors, healthcare use, asthma treatment, and monitoring and use of asthma action plan. Descriptive statistics and stepwise logistic regression were used in data analysis. Results A total of 1280 patients were recruited; 85.3% adults and 14.7% children aged 5–17 years old. Only 34.1% of adults had well‐controlled asthma, 36.5% had partly controlled asthma, and 29.4% had uncontrolled asthma. In children, 54.3% had well‐controlled asthma, 31.9% had partly controlled, and 13.8% had uncontrolled asthma. More than half had experienced one or more exacerbations in the last 1 year, with a mean of six exacerbations in adults and three in children. Main triggers for poor control in adults were haze (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.13–2.01); cold food (OR 1.54; 95% CI 1.15–2.07), extreme emotion (OR 1.90; 95% CI 1.26–2.89); air‐conditioning (OR 1.63; 95% CI 1.20–2.22); and physical activity (OR 2.85; 95% CI 2.13–3.82). In children, hot weather (OR 3.14; 95% CI 1.22–8.11), and allergic rhinitis (OR 2.57; 95% CI 1.13–5.82) contributed to poor control. The majority (81.7% of adults and 64.4% of children) were prescribed controller medications, but only 42.4% and 29.8% of the respective groups were compliant with the treatment. The importance of an asthma action plan was reported less emphasized in asthma education. Conclusion Asthma control remains suboptimal. Several triggers, compliance to controller medications, and asthma action plan use require attention during asthma reviews for better asthma outcomes.


| INTRODUCTION
Asthma is a major and increasing health concern in Asia. 1 In Malaysia, the prevalence is estimated at 8.9%-13.0% in children 2,3 and 6.3% in adults. 4 Although asthma is a preventable condition, the prevalence of poorly controlled asthma is still high and has a substantial impact on the use of public health care resources and health expenditure. 5 The Malaysian National Health and Morbidity Survey reported that every year, 20% of adults with asthma visited the emergency department for acute exacerbations, and 10% of these were admitted. 6 Another local study on 311 children with asthma reported about half of them had poor control and that a third had emergency visits for asthma in the previous 1 year. 2 The high cost of asthma management was due mainly to hospitalization and medication. 7 Mortality for asthma in Malaysia has also increased since 1990 by an average of 0.6% a year, which is preventable. 8 The main aim of asthma management is to achieve and maintain good asthma control. Primary care plays a pivotal role in providing optimal asthma care, but currently several limitations exist.
Most patients' knowledge about asthma is poor, with reports stating limited provision of education on the disease and its treatment. 2,9 Effective medications are available but local qualitative study has reported suboptimal use of inhaled controller medications amongst children with asthma and most used complementary and alternative medication (CAM) for self-treatment instead. 10 Despite overwhelming evidence for supported self-management, 11 the uptake of education on asthma and self-management skills in Malaysia is low. 9 Determining risk factors for poor asthma outcomes can potentially help target the provision of asthma management in the primary care settings. Our overarching aim was to define a population at greater risk of poor control; to describe the monitoring and treatment, and to report on the provision of asthma care. In this study, we intend to establish a cohort of patients to improve our understanding of the complex factors related to disease burden and to inform the development of quality improvement initiatives in our primary care settings.

| Setting
This cross-sectional study was carried out between July 2019 and January 2020 in six public health clinics in the Klang District, Malaysia. The Klang District was chosen because it is a densely populated district with a mix of rural, suburban and urban settings. [12][13][14][15] The six chosen health clinics cater for a low-and middle-income population. They are government-funded clinics in which patients pay a nominal fee of MYR 1 (USD 0.24) per visit for consultation, investigation, and treatment. 15 Senior citizens, children, and government employees receive free treatment.
The prevalence of asthma in Selangor was reported to be 5.9% in 2011. 16

| Participants and sampling
Sample size was calculated to enable assessment of a proposed improvement initiative using the G*Power 3.1 software using estimates from a meta-review of supported self-management of asthma. 17 A total of 766 patients were required to have an 80% chance of detecting significance at the 5% level a decrease in the primary outcome measure (proportion with an unscheduled consultation) from 22% in the control group to 14% in the experimental group. To allow for an estimated dropout rate of 40%, 18 we recruited 1280 patients aged 5 years and above with physician-diagnosed asthma and/or receiving asthma treatment in the previous year. Patients with respiratory symptoms (e.g. cough, breathlessness, wheezing) due to respiratory infections without underlying asthma, chronic obstructive pulmonary disease (COPD), congenital heart disease, gastroesophageal reflux, heart, liver or renal failure, active life-threatening malignancy and those receiving palliative care were excluded.

| Recruitment
These health clinics did not have registers of people with asthma; hence patients were recruited during their routine visits to the clinic.
We obtained written informed consent from patients upon recruitment. For children aged 7-17, age-appropriate assent and parental consent were sought. For children aged below 7, only parental consent was sought. 19 All patients who fulfilled the inclusion criteria and consented, were screened with handheld spirometry (if not contraindicated) using the Vitalograph ® micro spirometer. 20 Those with an FEV 1 /FVC ratio below 0.7, were asked to return within 2 weeks to perform formal bronchodilator reversibility testing with the ndd EasyOne Air spirometer. 21 We included patients who demonstrated reversibility (defined as having an FEV 1 value increase by 200 ml or more or an increase of 12% and above from baseline). 22 If the patient did not demonstrate reversibility they were classified as having COPD and were excluded. Patients who had achieved an FEV1/FVC ratio of 0.7 and above (i.e., normal spirometry) were included in the study based on clinical diagnosis. Patients who were unable to perform the handheld spirometry appropriately or whose spirometry results were inconclusive were invited to a repeat assessment within 2 weeks to clarify the diagnosis.

| Data collection
There were two types of data collected: data from face-to-face questionnaires and clinical assessments. The questionnaires included sociodemographic characteristics, healthcare use, and related payment, current asthma status, comorbidities, asthma treatment, use of asthma action plan (AAP), asthma education, and EuroQol-Visual Analogue Scale (EQ-VAS). EQ-VAS is a tool to self-rate overall measure of health status on a vertical scale of 0-100 (worst to best) 23 at the time of recruitment. For children, the questionnaires were usually answered by their parents or carers, although a few older children completed the questionnaire themselves with the help of their parents. Clinical assessments included blood pressure and peak flow measurements. Asthma control was evaluated using GINA assessment of asthma control (GINA 2017) and was categorized into well-controlled, partly controlled, and uncontrolled. 22 Data were also retrieved from patients' medical records to ensure clarity on the reason of visit at the point of recruitment; these include asthma diagnosis with spirometry measurement (if available), degree of asthma control, previous peak flow measurements, education on inhaler technique, and prescribed treatments.      Table 2 summarizes the level of asthma control and related risk profiles.

| Asthma education
More than 90% of the patients had received asthma education.
However, the emphasis on specific education varied; education on inhaler technique was the usual focus, whereas the importance of asthma diary and AAP was less emphasized.

| Interpretation in relation to other literature
The prevalence of suboptimal asthma control was consistent with findings of previous studies; 34% of adults in different health clinics in Selangor, Malaysia, 27 and 18% in studies in Southeast Asia. [28][29][30] We found that self-reported exposure to haze, air-conditioning, extreme emotion, and physical activity were significantly associated with poor control in adults. A probable reason could be adults are more likely to engage in work-related activities, either indoor, or outdoor. While avoiding these triggers whenever possible is important, action plans should include advice for stepping-up controller medications if patients encounter triggers, for example, during the haze or when doing physical activity. 31 In contrast, hot weather and allergic rhinitis were risk factors for poorly controlled asthma in children. A recent review determining the relation between ambient temperature and exacerbations of asthma in children had reported extreme hot or cold were common triggers. 32 It is believed that this occurred in children with eosinophilic endotype, the hypothesis being that hot and humid weather (as in Malaysia) facilitates microorganisms or mites to grow in the respiratory tract. 33,34 The importance of addressing the link between rhinitis and asthma has been highlighted in the World Health Organization (WHO) report and recommended in several guidelines. 35,36 In this study, allergic rhinitis was associated with poorly controlled asthma in children but not in adults, although the proportion of patients with allergic rhinitis is similar. Possible reasons for this difference include the severity of allergic rhinitis, and undertreated (or untreated) allergic rhinitis in children. A study on children with asthma and allergic rhinitis reported that only a third received proper rhinitis treatment. 37 One observational study reported the association of poor controlled asthma and allergic rhinitis was only in children who were not on treatment or only on oral antihistamines/montelukast compared to those who used nasal corticosteroids. 38 T A B L E 4 Odds ratios and 95% confidence intervals in the final model after stepwise model selection for poor asthma control in adults The association of the male gender with poorly controlled asthma has been reported in several studies. 39,40 Whilst this may reflect different phenotypes of asthma, it may also be due to differences in exposure to triggers or in attitude towards treatment.
Earlier studies had reported relation to men's health-seeking behavior and attitude towards adherence to asthma treatment in particular the inhaled corticosteroids (ICS). 41,42 In this study, we noted that among those who did not use CAM,  43,44 and those who used CAM were observed to be more proactive towards their asthma selfmanagement. 43 However, the effectiveness of CAM remains unclear.
A survey in Canada showed that CAM use was associated with poorly controlled asthma, but a recent systematic review showed no clear conclusion was reached. 45,46 We showed that evidence-based interventions were associated with increased odds for poor control; taking controller medications, education on inhaler technique, and provided AAP for asthma selfmanagement may represent 'confounding by indication,' as healthcare providers appropriately targeted care on the higher-risk individuals. Confounding by indication occurs because clinicians are more likely to provide evidence-based interventions to patients with more severe disease, this resulted with recommended treatments appear to link with poorer outcomes. 47 For example, our findings that controller medications and action plan ownership were associated with an increased risk of acute attacks in children (despite robust evidence that they both prevent exacerbations), have been identified as confounding by indication in other studies. 48,49 In our study, the prescription of controller medications (mainly ICS) seemed appropriate (82% in adults and 64% in children in the last 12 months). However, only about half of the patients reported being compliant with this treatment. A similar trend was seen across the Asia-Pacific region, where the use of ICS remains low despite the implementation of national guidelines on ICS recommendations. 50,51 We found about half of the adults and a quarter of the children reported use of SABA more than twice a week. Patients may rely on SABA for quick-acting relief instead of the delayed clinical benefits provided by ICS, leading to the underuse of controller medications. 52 Overuse of SABA is significantly associated with asthma morbidity and mortality. 53 This highlights a worrying trend, and education on asthma medications is the key to improve the situation.
The use of asthma diary and AAP in this population was suboptimal. Less than a third of these patients had been given AAP despite extensive evidence-based reviews concluding that asthma self-management supported by regular healthcare professional review improves asthma control, and reduces exacerbations and admissions. 54 This is similar to findings in the Asthma Insights and Reality in Asia-Pacific (AIRIAP) study in which only 18% of the respondents had been given a written action plan and this did not take into account whether the action plan was used or used effectively. 50,55 Supported self-management of asthma should be emphasized in primary care practice. A pictorial asthma action plan or mobile applications on self-management tailored to patients' or carers' needs could be explored to improve compliance to medication and self-monitoring. [56][57][58][59] The prevalence of smoking in people with asthma have been reported to be similar to the general population. 50 We found a relatively low prevalence of current smokers, 9.5% in adults and 1.6% in children, compared to the Malaysian national average of 21.3% among adults. 16 It is worrying that almost half of our patients reported being exposed to second-hand smoke; in children, fathers were the main source. Passive smoking is a recognized risk factor for poor asthma control. 60 Secondhand smoke can be reduced if the family members are made aware of the risks. The Malaysian government had implemented smoke-free legislation in public spaces, a step towards protecting the public from second-hand smoke. 61 Obesity has been linked with poor asthma control 62,63 and is not described as a phenotype of asthma. 22 We did not show any significant association between obesity and asthma control, although there was a high proportion of overweight and obese patients.

| Strengths and limitations
The strength of this study was the wide age range of patients who participated (5-87 years old).

| CONCLUSION
Our study revealed that the status of well-controlled asthma is yet to be achieved in these patients. Although this study was limited by its convenience sampling, the baseline findings have provided important input to inform a better strategy in improving patients' asthma status.
Several identified triggers deserve attention during asthma reviews.
Non-adherence to controller medications despite a good rate of prescription, frequent use of SABA, and underutilized asthma selfmanagement needed to be re-emphasized to improve and sustain better asthma outcomes.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

TRANSPARENCY STATEMENT
The lead author Ee Ming Khoo affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.